Transitional Nurse

Job description

Job responsibilities

a) Main purpose of job

Shooting Star Childrens Hospices (SSCH) aims to make the transition from childrens to adult services as seamless as possible to allow young people to live their lives as independently as possible, according to their wishes, whilst receiving the care and support they and their families need.

The post holder will identify and build relationships with services providing care and support for young people and adults with palliative care needs or life limiting conditions. The post holder will support and advise young people likely to transition to adult services, identifying these at an early stage so that a transition plan involving all key stakeholders is in place.

b) Work relationships

SCCH care is delivered by four clinical areas under the direct operational management of the Heads of Care. The nature of transition and safeguarding work necessitates good relationships, awareness and understanding of these clinical areas, multi-disciplinary professionals, and the wider work of the charity:

Inhouse

Community Nursing

SPACE (specialist palliative care team)

Family Support Services (psychosocial care)

The Transitional Nurse sits within the Social Work and Transition Team which is one of the Family Support Services. The post holder will work collaboratively with the other family support services (family support work, counselling, therapies and care events), supporting also the in-house service, the community nursing team and symptoms management team with matters concerning transitional care. The Social Work and Transition Team is managed by the Designated Safeguarding Lead.

The individual in this role will work in partnership with internal and external health, education and social care professionals involved in the care of SSCH young adults and families, including external professional networks focused on improving transitional care.

c) Scope of job

The postholder is responsible for delivery of the SSCH Transition Care Pathway, sensitively offering support to families at key timepoints, to ensure young people and families are provided with opportunity to receive expert guidance and support concerning transition to adult services.

Ensuring and enhancing the quality, safety and effectiveness of transition care offered to SSCH children and families. This involves continually developing professional knowledge and skills to respond to evolving needs within childrens and adult palliative care and providing training to the wider teams.

Within the team, the post holder contributes to the continual multi-disciplinary assessment of families needs, developing our resource and helping to engage other professionals internally and externally involved in specialist support.

Appointments for families may take place virtually or in-person at Shooting Star House or Christophers. Some travel to schools, colleges, residential settings and family homes may be required. Hospice Care is provided 24 hours a day, 365 days a year, therefore the post holder may be required to work occasional Saturdays or Sundays.

Main duties and key responsibilities

Transition Care Pathway

Implement the SSCH Transition Care Pathway, identifying families of young people aged 14 and inviting them to learn more about support available through Q&A sessions, the SSCH website Family Zone and individual enquiry.

Contact families of young people aged 16 and offer a transition assessment of needs.

Re-offer this individualised support to young people and families following a young persons 18th birthday.

Shape this direct work with young people and families, individualising this to needs outlined in the assessment. This may include ensuring understanding of the various transitions between health, education and social care services as a young person reaches adulthood, providing expert advice, attendance at multi-agency meetings, advocacy, emotional support and signposting.

Support families in creating their handover document/checklist, enabling a comprehensive presentation of needs, wishes and previous care/support.

Make contact with young people and families following a young persons 20th birthday, discussing expectations and preparing them for transition/discharge on their 21st birthday.

Manage a caseload of transitioning young people, ensuring the development and delivery of their transition plan and enabling end of service/discharge planning in line with organisational policy and guidance.

Manage this caseload effectively in order to ensure prioritisation of need and throughput, so that this care provision is as accessible as possible to families.

Work with young people to ensure their transition plan is regularly reviewed to ensure it remains relevant and accurately reflects their needs and goals.

Provide advocacy and other appropriate professional interventions to enable the needs of young people and their families experiencing transition to achieve their goals.

Advise and support young people and families to access appropriate financial support for young people, putting them in touch with the appropriate agencies.

Facilitate meetings, events, group support and education for young people and their parents in relation to facilitating independence and the transition to adult services.

Participate in external multi-disciplinary meetings with other statutory and non-statutory organisations and agencies relating to children, young people and their families. E.g. Child in need meetings, child protection case conferences.

Transition Care Expertise

Be the first point of contact for transition care queries from care staff. This will involve providing advice and guidance on a wide range of issues and working in partnership with these team members to ensure effective outcomes for children, young people and families.

Advise care staff in supporting decision making when a young person or adult may lack capacity, in line with current legislation, understanding the ramification of the Mental Capacity Act and Deprivation of Liberty safeguards, ensuring the care team take account of the requirements under the Mental Capacity Act.

Facilitate the assessment of families needs in relation to family functioning, capacity, resilience and emotional risk, parenting styles/ attachment issues.

Support staff to do everything in their power to ensure a young persons capacity can be assessed and to ensure were providing the least restrictive care for the individual.

Identify training needs and assist in developing and delivering appropriate programmes, specifically in the areas of mental capacity act, deprivation of liberty safeguards, advocacy and supervision.

Address safeguarding concerns appropriately following SSCH policy and contributing knowledge appropriate to safety planning and ongoing care.

Work collaboratively with partner agencies across health, social care, education and others to safeguard children and adults at risk and promote welfare.

Participate as an active member of the Transition Team, contributing to multi-disciplinary psychosocial meetings to ensure all families at Shooting Star receive support suitable to their needs. Including Specialist Psychosocial MDT, Hospice MDT, Safety Huddle, Morbidity and Mortality Meeting, Hospice Core Groups, Journal Club and other multi-disciplinary team meetings.

Understanding the network

Identify young people and adult services providing day care, short break care, palliative and end of life care.

Identify both education and work opportunities for young people, creating links with external providers including colleges, universities and careers advisors.

Identify potential housing partners with provision for supported independent living arrangements.

Represent SSCH at local and regional meetings, raising awareness and building partnerships.

Quality and improvement

Demonstrate safe clinical practice in all aspects of your work with families. Maintain awareness of current developments in pediatric and adult palliative care and the implications for practice.

Establish and maintain mechanisms for obtaining the views of young people in relation to the services provided at the hospices.

Contribute to service evaluation or audit to ensure equity of service and maintain high quality service provision.

Ensure accurate and contemporaneous notes and records of all contacts are recorded within the electronic notes system.

Produce written reports to a high standard, when requested.

Recognise discriminatory practices and appropriately challenge service users, colleagues, and senior staff

Manage own time and prioritise workload, providing a flexibility in the service delivery that is responsive to families individual and changing needs.

Behave at all times in a manner that is sensitive to the differing cultural, social and spiritual needs of children, young people and their families.

Represent SSCH at external meeting, acting as an ambassador for this extensive provision of care.

Contribute to the development of policies and protocols that facilitate safe, effective and timely information sharing processes, reflecting current legislation and national policy.

Person Specification

Knowledge and Skills

Essential

• - Demonstrate comprehensive understanding and use of knowledge related to area of practice.
• - Acquire and review national learning and information concerning transitional care.
• - Knowledge and understanding of frameworks for safeguarding assessment and intervention.
• - Knowledge of relevant local and national services that support young people with life-limiting conditions and their families. Awareness of the range of services likely to be involved during transition.
• - Understanding of the needs of families experiencing bereavement, and the ability to advise families and professionals concerning appropriate support.
• - Awareness of relevant research concerning transition and research concerning childrens palliative care, in order to ensure quality of care.
• - Ability to work as an autonomous practitioner and member of a team.
• - Excellent communication skills.
• - Ability to work with issues of equality and diversity within client and organisational contexts.
• - The ability to work on own initiative and under pressure.

Qualifications

Essential

• - Recognised nurse qualification (BSc or equivalent)
• - Registered to practice with the NMC

Experience

Essential

• Sufficient post qualifying experience in relevant areas of practice including pediatric/adult nursing.
• Some experience of supporting and empowering young people and their families transitioning to adult services.
• - Experience of working within a multi-disciplinary health team.
• - Excellent communication and negotiating skills.
• - Experience of building relationships with a wide range of organisations and agencies.
• - Experience of using client databases.
• - Intermediate IT skills using MS Word, Excel and Outlook.
• - Ability to recognise and manage ones own stress/wellbeing.
• - Car owner/driver with full UK drivers licence, with appropriate personal and business use insurance.

Desirable

• - Experience of negotiating transitions between healthcare teams for young people.
• - Experience of working with children, young people and their families affected by life-limiting illness in a palliative care environment.
• - Qualified as a Mental Capacity Act/DoLS Best Interest Assessor
• - Experience of conducting assessments/consultations on a virtual platform.
• - Previous experience of delivering training.
• - Experience of conducting research.
• - Leadership skills.

General attributes

Essential

• - Ability to work effectively with teams and individuals across the organisation.
• - Empathetic and sensitive to others needs.
• - Able to build good relationships with others (including staff, volunteers, children and families known to SSCH and external professionals.
• - Organised, methodical and able to multi-task.
• - Flexible and willing to undertake varied responsibilities as part of a team.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Shooting Star Children’s Hospices

Address

Shooting Star Childrens Hospice

The Avenue

Hampton

Middlesex

TW12 3RA

Employer's website

https://www.shootingstar.org.uk/ (Opens in a new tab)